I agree that all blood tests should be followed up by the orderer and that the lab should communicate critical results. These have been my policies always. .

Dr Peter Boylan tells Kivlehan inquest of deficiencies in care
Expert witness gives evidence on final day of hearing into woman’s death

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An undated picture of Dhara Kivlehan and her husband Michael.

Marese McDonagh

Mon, Sep 29, 2014, 17:30

First published: Mon, Sep 29, 2014, 12:46

An expert witness has told the inquest into Dhara Kivlehan’s death that a delay in getting specialist renal and liver care for her was one of a number of material contributors to her death.

A verdict in the inquest is expected at the Coroner’s Court in Carrick-on-Shannon, Co Leitrim, today.

Dr Peter Boylan said it was clear to him there were deficiencies in both Ms Kivlehan’s clinical care and at systemic level, which were “material contributors” to her death.

Ms Kivlehan (29), died of multi-organ failure due to HELLP syndrome, a severe form of pre-eclampsia, in Belfast’s Royal Victoria Hospital on September 28th, 2010. She had been airlifted from Sligo Regional Hospital four days earlier.

Among the deficits in clinical care which the consultant obstetrician highlighted in the case were the attribution by staff at Sligo Regional Hospital of all her problems to HELLP syndrome . He told the jury she should have been referred to both a liver and renal consultant earlier.

The former master of the National Maternity Hospital said that failure to seriously consider the possibility of intra-abdominal haemorrhage in the post-operative period and delay in transfer to a tertiary centre – ideally St Vincent’s University Hospital Dublin – were also factors.

The system failures which Dr Boylan highlighted were the lack of prompt availability of specialist renal and liver input at Sligo Regional Hospital .

Another factor was the lack of intensive care beds at tertiary hospitals in Dublin and Galway. Dr Boylan added that the lack of continuity of care at consultant level due to an insufficient number of obstetric consultants on staff at the Sligo hospital were also factors.

He stressed Ms Kivlehan had presented in a most unusual way with both severe liver and renal failure.

Dr Boylan said if she had been transferred to a tertiary centre in Dublin or Galway it might have made a difference, “but it is hard to say”.

He said it was an “error of judgment” that one Sligo-based consultant had queried whether her swollen abdomen was due to internal bleeding, but that this was not investigated further.

The consultant agreed with Damien Tansey, solicitor for the Kivlehan family, that a delay in acting on blood results taken when Ms Kivlehan was admitted to the hospital on September 20th was “certainly a deficiency in care”. The inquest has heard the results were not accessed for 12 hours.

Mr Boylan said he was not trying to excuse in any way the lack of keenness to source results, but wanted to explain what happened in terms of everyday life in a hospital.

Mr Tansey put it to the expert that if the blood tests had been acted on quickly, Ms Kivlehan might have had an emergency caesarean section 12 hours earlier, and then staff could have focused on her liver and kidney problems.

Dr Boylan pointed out that she showed sign s of “clonus” after being admitted, which staff interpreted as possible onset of seizures related to pre-eclampsia – but in fact this was more likely to have been linked to liver failure. He said staff were presented with “a very complex situation”.

Dr Boylan said Ms Kivlehan suffered a significant intra-abdominal bleed after her emergency caesarean section.

Her abdominal swelling was mistakenly attributed to ascites (fluid in the abdomen) , probably in association with her liver failure.

He said Ms Kivlehan presented a very “difficult management problem”, but there was undoubtedly a misinterpretation of her abdominal distension which was incorrectly not attributed to abdominal bleeding.

“It is debatable, however, whether or not earlier intervention to deal with this problem would have made a significant difference in the long-term, given the extremely complicated nature of her presentation,” he added.

“Nevertheless, had this intra-abdominal haemorrhage been recognised and dealt with, and an earlier transfer to a tertiary centre organised, it is possible that the outcome might have been different. This however remains conjecture.”

The hearing continues.

Dhara Kivlehan’s death was due to medical misadventure a jury has found following a five-day inquest.

The jury recommended that all blood tests be followed up by the doctor who ordered them and that any critical issues be flagged by laboratory staff.

After just under an hour deliberating, the jury of five men and two women also recommended that, without delay, a database of all available critical care beds be made known to all hospitals, regional and national.

Michael Kivlehan appealed to other fathers not to be afraid to challenge doctors. “I would like to get the message out there to lay people that child birth is not always that simple”, he said. “And to tell the fathers they need to be more supportive of their women, especially if they have any concerns – and to have the strength to challenge doctors.”

Referring to his experience of some staff in Sligo, he said medics should improve their bedside manner.

Speaking after the verdict, Coroner Eamon MacGowan wished the Kivlehan family peace, tranquillity and contentment. “Michael has vindicated Dhara’s life and explained it through his campaign to have this inquest heard. I am sorry it has taken four years to do so,” said Mr MacGowan.

Poignantly, the 35-year-old Mr Kivlehan was carrying a montage of photographs of Dhara yesterday, including one of the couple with their newborn son taken in Sligo hospital.

While Sunday was the fourth anniversary of Dhara’s death, he said Tuesday was the real anniversary as far as he was concerned. “Tuesday was the day they switched off the machine,” he said.

Michael said his wife loved Ireland and had “an Irish sense of humour”. He said that his son Dior had become aware of the publicity surrounding the inquest. “When he sees her photograph on television he says ‘there’s Mammy’. He says ‘Mammy is up in heaven’.”

His solicitor Damien Tansey said it had been a David and Goliath battle.

Earlier, Mr Tansey told the inquest that Mr Kivlehan had been overjoyed when she became pregnant.

He said the couple had been in the first flush of their courtship when Michael had a near-death experience following a road traffic accident and he had been in hospital in London for several months with kidney failure.

“And who was the constant support at his side?. Dhara was. She never left his side”, the solicitor added.

He said that Dhara’s pregnancy was normal until close to the end, but when she was admitted to hospital on September 20th, 2010 – eight days before her death – her legs were swollen from the knees down.

Staff treated her case as pre-eclampsia, blood tests were done, but for some reason “that has still not been explained” the results were not processed for 12 hours.

The inquest heard that one of the recommendations of a HSE review carried out after Mrs Kivlehan’s death was that a database of available ICU beds be compiled for the benefit of all hospitals nationwide. Mr Tansey said that, four years on, this has not been done.